197607880-1-23-2025-29-AS-EMOY-DD82EQ-20250123162018

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607880
Report Date: 01/23/2025
Date Signed: 01/23/2025 04:20:40 PM

Document Has Been Signed on 01/23/2025 04:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FOUNTAINVIEW AT EISENBERG VILLAGE		FACILITY NUMBER:	197607880
ADMINISTRATOR/ DIRECTOR:	ADAM PENA		FACILITY TYPE:	741
ADDRESS:	6440 WILBUR AVENUE		TELEPHONE:	(818) 654-5534
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 216		CENSUS: 104	DATE:	01/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	ADAM PENA - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 09:45am. Upon arrival LPA was greeted by front door receptionist, explained the reason for the visit and to inform their Administrator. LPA met with Executive Director Adam Pena and Clarissa Townes Director of Health care services the reason for the visit was explained. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. At approximately 10:37am LPA inspected nine (9) randomly selected bedrooms (RM 100, RM 108, RM 110, RM 202, RM 310, RM 317, RM 321, RM 425, RM 429) throughout the four (4) occupied floors. The resident bedrooms were properly furnished with a bed, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Restrooms: The resident restrooms appeared clean, sanitary and in operating condition with grab bars and non-slip surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. From 10:59 am – 12:02 pm the hot water was measured in all rooms and ranged between 110.0 – 120.4 degrees Fahrenheit all within the required range. At 11:23am, LPA activated a resident pendant, and observed staff respond in approx. 1 min by phone call to the resident’s room. It was noted that the policy is to call the resident rooms first to check if assistance is needed or if it was an accidental call. If the resident does not answer the call staff typically respond within 5 minutes. During the inspection LPA observed, evacuation chairs in each stairwell. (PAGE 1)(Report Continued on LIC 809C PAGE 2...)

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAINVIEW AT EISENBERG VILLAGE	FACILITY NUMBER: 197607880
	VISIT DATE: 01/23/2025

NARRATIVE

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(PAGE 2)(Report Continued from LIC 809C PAGE 1...)

LPA inspected the kitchen/food service area and observed that knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food.

LPA inspected the common areas throughout the facility inside and out. All areas have been appropriately furnished. The common areas were observed to be properly furnished and relatively clean at the time of the visit. LPA observed sanitizer readily available in areas with high touch surfaces. Dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility, fully charged and last serviced Jan, 31, 2024 and are scheduled for service on Jan. 30 2025. LPA observed all required postings throughout the facility.

The Administrator provided the fire protection equipment performance report dated 07/18/2024 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. The last emergency disaster drill took place on 12/23/2024 and conducted quarterly reflecting all shifts scheduled. On the basement level, LPA observed a movie theater, two (2) locker room areas for male and female employees along with a food storage pantry. Additional non-perishable foods were also observed in the food storage pantry. The parking garage was accessible from the basement but locked from the outside and monitored by security. LPA observed an adequate supply of emergency food and water stored in this area. LPA did not observe any obstructions or hazards during the visit.

Resident Records and Personnel records were reviewed from approx. 11:51 am – 1:30 pm. LPA Mosley reviewed Resident Records at approx. 11:51 a.m. Ten (10) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files in order at the time of the visit.

(PAGE 2)(Report Continued on LIC 809C PAGE 3...)

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAINVIEW AT EISENBERG VILLAGE	FACILITY NUMBER: 197607880
	VISIT DATE: 01/23/2025

NARRATIVE

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(PAGE 3) (Report Continued from LIC 809C PAGE 2...)

At approx. 12:38 pm Eight (8) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files in order at the time.

Medications review began at approximately 1:50pm The medications are centrally stored in a med room on the fourth floor inaccessible to residents in care. Medication assistance is provided to eight (8) residents at this time. LPA conducted a medication review on six (6) randomly selected residents. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. No errors observed during review.

Infection Control / Emergency disaster planning: During today’s visit the LPA Mosley reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control are adequate.

Daily vehicle Inspection report was reviewed for facility vehicles. All records were in order.

LPA conducted seven (7) resident and seven (7) staff interviews from approx. 10:55am- 2:04 pm. Staff interviews revealed that staff are knowledgeable in resident rights, different forms of abuse and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit.

LPA obtained the following documents – Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.
Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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